Empiric Broad-spectrum Antibiotics Research Articles

Hemophagocytic Lymphohistiocytosis As an Immune-Related Adverse Events in a Patient with Advanced Lung Adenocarcinoma

I ntroduction: Immune checkpoint inhibitors (ICIs) have been approved as single agents or in combination with cytotoxic chemotherapy for use in the treatment of different tumor types including skin, lung, kidney, endometrium, bladder..., especially in advanced stages. ICIs are usually well tolerated and despite their demonstrated clinical benefit, severe immune-related adverse events (irAEs) can sometimes occur, including colitis, hepatitis, myocarditis, glomerulonephritis, pneumonitis, hypophysitis... Here we are reporting a case of hemophagocytic lymphohistiocytosis (HLH), a rare but potentially life-threatening complication of ICI therapy. Case presentation: We present the case of a 60-year-old female with metastatic adenocarcinoma of left lung who presented to the emergency room with a week history of generalized weakness, worsening dyspnea on exertion and decreased appetite while on maintenance ICI with pembrolizumab for approximately 1 year. On admission vital signs were a blood pressure of 88/70mmhg, pulse rate of 139 beats per minute, respiratory rate of 20 cycles per minute, temperature of 98.3°F and oxygen saturation of 98% on room air. Physical exam was unremarkable. A complete blood count revealed leukopenia of 2.7k/uL, hemoglobin of 11.8 g/dL, and mild thrombocytopenia of 131k/uL. A basic metabolic panel was significant for hyponatremia of 133 mmol/L, blood urea nitrogen of 43mg/dL, and creatinine of 1.71mg/dL. She was started on empiric broad-spectrum antibiotics with IV vancomycin and cefepime due to concern for infection in the setting of recurrent febrile episodes and neutropenia. Worsening pancytopenia prompted further work-up and showed elevated ferritin of 19581, lactate dehydrogenase of 2380, folate > 20, vitamin B 12 of 1645, iron level of 62, elevated total and direct bilirubin of 6.3 and 2.9 mg/dL, haptoglobin < 10 mg/dL, fibrinogen level of 174, C- reactive protein of 73.9. Elevated soluble IL2- receptor elevated at 10336.7, d-dimer > 20, elevated partial thromboplastin time of 51.1, Prothrombin Time of 20.5, INR of 1.7. Peripheral blood smear was unremarkable. Hemophagocytic lymphohistiocytosis was suspected and a bone marrow was performed prior to initiation of intravenous steroids. Bone marrow showed evidence of abundant histiocytes with hemophagocytosis of nucleated cells. She was discharged on an oral steroid taper. She has since been well without evidence of tumor progression off therapy for over 2 years now. Discussion: HLH is a rare but potentially life-threatening complication of ICI therapy that requires prompt recognition and management. Our patient responded well to steroids and did not require cytotoxic chemotherapy with etoposide.

CLINICO-MICROBIOLOGICAL SPECTRUM OF HEMODIALYSIS CATHETER-RELATED BLOOD STREAM INFECTIONS: A CONCISE REVIEW

The disease burden of chronic kidney disease is increasing worldwide, and with the growing population of patients requiring hemodialysis, more patients are placed on central venous catheters (CVCs). Vascular access infections significantly cause hospitalization and mortality among end-stage renal disease (ESRD) patients. As per the data from the United States, Gram-positive organisms account for almost 56% of the total cases of catheter-related bloodstream infection (CRBSI), in stark contrast to Indian studies showing a dominance of Gram-negative organisms. The prolonged use of non-tunnelled catheters, poor hygiene, lack of catheter care protocols, and the tropical climate pose unique challenges to control CRBSIs in resource-poor countries. The most effective strategy to prevent CRBSI is to minimize the duration of dialysis catheters. Other strategies include the introduction of strict catheter care protocols, using tunnelled cuffed catheters, anti-microbial lock solutions, and topical antimicrobials. Eradicating nasal carriage of Staphylococcus aureus also reduced the incidence of CRBSIs.Treatment of suspected CRBSI should be promptly initiated with empirical broad-spectrum antibiotics covering Gram-positive and Gram-negative organisms. Catheter removal is indicated only if the patient is clinically unstable, has metastatic infections, and those who do not respond to antibiotic therapy.

Can high procalcitonin levels be a biomarker for detecting multidrug-resistant Gram-negative bacteremia?

Aims: Clinicians prefer broad-spectrum empirical antibiotic therapy in patients with suspected bloodstream infection (BSI) due to long test turnaround times of conventional methods. We aimed to assess the contribution of procalcitonin (PCT) to the selection of antibiotics to be used in empirical treatment.
 Methods: The results of inpatients whose blood cultures and samples for PCT tests had been sent simultaneously between 2018 and 2022 were analyzed retrospectively. Antibiotic susceptibility results of Enterobacteriaceae, Acinetobacter baumannii complex and Pseudomonas aeruginosa, were evaluated for multidrug-resistance (MDR). 
 Results: Results of 1206 patients who met the inclusion criteria were included in the study. The PCT median value in BSIs caused by the Gram-negative bacteria found to be statistically significantly higher than those caused by the Gram-positive bacteria, fungal and polymicrobial infections (p

A 20-Year Study of Intracranial Pyogenic Complications of Sinusitis in Children.

Intracranial pyogenic complications of sinusitis in children can lead to serious sequelae. We characterize the clinical, epidemiologic and microbiologic characteristics of children with such complications over a 20-year period. Single-center retrospective chart review. Cases were identified based on International Classification of Diseases diagnostic codes (ICD)-9 and ICD-10 depending on the year and by reviewing all intracranial microbiologic samples. A total of 104 cases of complicated sinusitis were included after review of 1591 charts. Median age was 12 (IQR 9-14); 72 were male (69%). The most frequent complications were epidural empyema (n = 50, 48%), subdural empyema (n = 46, 44%) and Pott's puffy tumor (n = 27, 26%). 52% (n = 54) underwent neurosurgery and 46% (n = 48) underwent otolaryngologic surgery. The predominant pathogen isolated from sterile site specimens was Streptococcus anginosus (n = 40, 63%), but polymicrobial growth was common (n = 24; 38%). The median duration of intravenous antibiotic therapy was 51 days (IQR 42-80). Persistent neurologic sequelae (or death, n = 1) were found in 24% (n = 25) and were associated with the presence of cerebritis and extensive disease on neuroimaging ( P = 0.02 and P = 0.04, respectively). Intracranial complications of sinusitis continue to cause significant morbidity in children. Polymicrobial infections are common, which reinforces the need for broad-spectrum empiric antibiotic therapy and cautious adjustment of the antibiotic regimen based primarily on sterile site cultures. The association of neurologic sequelae with the presence of cerebritis and extensive intracranial involvement on neuroimaging suggest that delayed diagnosis may be a contributor to adverse outcome.

Controversies in the microbiological diagnosis and treatment of bone and joint infections

Recently, bone and joint infections such as fracture-related infection (FRI) and prosthetic joint infections (PJI) have been defined for clinical and research purposes. National and international guidelines are being produced to guide clinicians towards what is considered best practice. However, much of what we do regarding the microbiological diagnosis and management of orthopaedic infection is based on expert opinion, rather than evidence-based medicine. This is largely because, prior to the publication of the clinical definitions of orthopaedic infection, studies included a heterogeneous population making comparisons between them difficult. More recently the publication of large clinical trials in the antimicrobial management of orthopaedic infection has demonstrated that such clinical research is possible, and can both challenge the existing dogma in this field and lead to universal changes in clinical practice. There is robust evidence for microbiological sampling techniques and their interpretation in diagnosis of orthopaedic infection, as well as the choice of empiric broad-spectrum antibiotics and the non-inferiority of oral versus intravenous systemic antibiotics. For other elements of the diagnosis and management of orthopaedic infection this is not the case. For example, there are limited or no data to support recommendations regarding time off antibiotics prior to microbiological sampling, systemic antibiotic duration, when to do a joint aspirate in PJI revisions or the timing of definitive joint implantation in the two-stage management of PJI. In summary, this review highlights what is currently considered best practice within the field of orthopaedic infection and discusses both the evidence behind it and where there is controversy or where further research is warranted.

A Case ofHematogenous Osteomyelitis ina 5-Week-Old Male.

Pediatric osteomyelitis is a rare diagnosis associated with devastating consequences when treatment is delayed. We report a case of hematogenous osteomyelitis in a 5-week-old male presenting to the emergency department (ED) with a flaccid right upper extremity. In the ED, the patient was evaluated with comprehensive infectious and trauma workups. Initial CT imaging of the head and X-ray imaging of the extremity were unremarkable. C-reactive protein was elevated at 0.8; all other laboratory markers were within normal range. Over the course of the ED evaluation, the extremity weakness spontaneously resolved; however, the infant developed a fever of 100.5 F. Empiric broad spectrum antibiotics were initiated, and the infant was admitted to the pediatric service. At 48 hours following presentation, cultures resulted positive for Staphylococcus aureus and MRI imaging revealed osteomyelitis of the proximal right humeral metadiaphysis. Given the subtle presentation of early hematogenous osteomyelitis, emergency providers should maintain a high index of suspicion for infection as the underlying cause in infants presenting with a flaccid extremity.

The role of culture-negative infection among infectious complications after total knee arthroplasty

Introduction Diagnosis of chronic periprosthetic joint infection (PJI) is difficult with the clinical signs of periprosthetic inflammation showing no growth of microorganism in the biomaterial. The frequency of culture-negative infection can reach 42.1 %. The objective of the study was to analyze outcomes of two-stage treatment of chronic PJI of the knee joint depending on the etiology of the infectious process.Material and methods A retrospective analysis of outcomes was produced for 103 patients: group I (n=30) showing no growth of microorganisms and group II (n = 73) demonstrating positive growth of pathogens. Knee PJI was diagnosed according to the 2018 ICM criteria. A favorable outcome suggested absence of recurrence for at least two years after reimplantation of endoprosthesis, arthrodesis, “life with a spacer” without signs of infection.Results Culture-negative infection was detected in 29.1 % (n = 30). Patients in the group were 1.5 times more likely to receive antibiotic therapy prior to admission and had average levels of CRP, ESR and articular leukocyte count being 1.5-2 times less than those in group II. Staphylococci (69.8 %) including MRSE (75 %) was the leading pathogen in group II. Recurrence of infection was 3.4 % in group I and 16.9 % in group II (p = 0.0928), the two-stage treatment was successful in 96.7 % and 74 %, respectively (p = 0.0064).Discussion Causes for the lack of growth of microorganisms in biological materials included previous antibiotic therapy, wound drainage, violations of the rules for sampling of biological material, absence of media for the growth of atypical microorganisms and the ability of microorganisms to form biofilms on implant surfaces. An emergency histological examination of the affected tissues was practical during surgery in doubtful situations for adequate surgical approach. The results of a meta-analysis (2023) showed that the replacement of an infected endoprosthesis was more effective for the treatment of a culture-negative infection compared to debridement and preservation of implant.Conclusion The culture-negative infection group in our series showed better success rate of a two-stage treatment of PJI using implant replacement and broad-spectrum empiric antibiotic therapy at a two-year follow-up period. The negative microbiological result in the group could be caused by antibacterial drugs administered prior to diagnosis of PJI.

Role of Antimicrobial Resistance in Outcomes of Acute Endophthalmitis.

This study explores local trends in antimicrobial resistance and its influence on long-term visual outcomes following treatment with broad-spectrum empiric intravitreal antibiotics. All patients undergoing intraocular sampling for endophthalmitis from Auckland between January 2006-May 2023 were included. The impact of antimicrobial resistance on the final visual outcome was analysed using logistic regression models. 389 cases of endophthalmitis were included, and 207 eyes (53.2%) were culture positive. When tested, all Gram-positive microorganisms were fully susceptible to Vancomycin, and all Gram-negative microorganisms demonstrated full or intermediate susceptibility to Ceftazidime. Resistance to at least one antimicrobial agent was present in 89 culture results (43.0%), and multidrug resistance (resistant to ≥3 antimicrobials) in 23 results (11.1%). No increase in resistance was observed over time. The primary procedure was a tap and inject in 251 eyes (64.5%), and early vitrectomy was performed in 196 eyes (50.3%). Severe vision loss (≤20/200) occurred in 167 eyes (42.9%). Antimicrobial resistance was associated with an increased risk of retinal detachment (OR 2.455 p = 0.048) but not vision loss (p = 0.288). High sensitivity to Vancomycin and Ceftazidime was present in our population, reinforcing their role as first-line empiric treatments. Resistant microorganisms were associated with an increased risk of retinal detachment but no alteration in final visual outcome.

Bacteraemia caused by Lactobacillus casei in a patient after cardiac surgery. A case report

BackgroundBacteria of the Lactobacillus family are a part of the physiological flora of the oral cavity, gastrointestinal tract, and urinary tract. We have used them in the food industry as probiotics and supplements. In some settings, rod-shaped lactic acid bacteria may become pathogenic. It may occur in immunocompromised or heart disease patients after cardiac surgery, patients with disturbed intestinal wall permeability, or those treated with broad-spectrum antibiotics.Case presentationWe present rare bacteraemia induced by the probiotic bacterium Lactobacillus casei in a 63-year-old patient after the attempted removal of ICD electrodes, complicated by acute regurgitation of the tricuspid valve. The patient underwent urgent cardiac surgery, the electrode elements were removed, and the tricuspid valve was replaced with a biological prosthesis. After surgery, the patient required intensive, multidisciplinary treatment with mechanical ventilation, continuous renal replacement therapy, broad-spectrum empirical antibiotic therapy, parenteral nutrition, and blood product transfusion because of multiple organ failure. On the 14th day of hospitalisation, the clinical symptoms of septic shock were observed. The microbiological investigation was performed, and Lactobacillus casei was cultured from a dialysis catheter sample. Dedicated antimicrobials were administered, and the patient was discharged home in good overall condition.ConclusionsThe present case shows that the promoted use of probiotics must be cautiously administered to patients in severe conditions, especially when accompanied by reduced immune system efficiency symptoms.

Appropriateness of Empirical Antibiotic Therapy in Hospitalized Patients with Bacterial Infection: A Retrospective Cohort Study.

The incidence of inappropriate and excessive empirical antibiotic therapy is unclear. The aim of this study was to determine the prevalence of different empirical antibiotic therapy prescriptions, related factors, and outcomes in hospitalized patients with bacterial infection. A retrospective cohort study was performed and patients with bacterial infection who were admitted between October 1, 2019, and September 30, 2020, were included. Multivariable analysis was performed by the logistic regression model. A total of 536 (42.6%) of the 1257 included patients received inappropriate empirical antibiotic therapy (IEAT), and 368 (29.3%) patients received appropriate but unnecessarily broad-spectrum empirical antibiotic therapy (AUEAT). MDRO (adjusted OR 2.932 [95% CI 2.201~3.905]; p < 0.001) and fever on admission (adjusted OR 0.592 [95% CI 0.415~0.844]; p = 0.004) were correlates of IEAT; sepsis (adjusted OR 2.342 [95% CI 1.371~3.999]; p = 0.002), age (adjusted OR 1.019 [95% CI 1.008~1.030]; p < 0.001), MDRO (adjusted OR 0.664 [95% CI 0.469~0.941]; p = 0.021), and urinary tract infection (adjusted OR 0.352 [95% CI 0.203~0.611]; p < 0.001) were correlates of AUEAT. Patients who received AUEAT were more likely to have a poor prognosis (63 [17.8%] vs 101 [27.4%]; p = 0.002). Both IEAT (median [IQR], 24,971 [13,135-70,155] vs 31,489 [14,894-101,082] CNY; p = 0.007) and AUEAT (median [IQR], 24,971 [13,135-70,155] vs 30,960 [16,475-90,881] CNY; p = 0.002) increased hospital costs. 45.3% (570/1257) of patients were infected with MDRO and 62.9% of them received IEAT. Inappropriate and excessive empirical antibiotic use was widely prevalent among hospitalized patients. Either inappropriate or excessive use of antibiotics may increase the burden of healthcare costs, the latter of which may be associated with poor prognosis. Clinicians need to be more judicious in choosing antibiotic(s). The MDRO epidemic was severe, especially in patients who received IEAT. It is imperative to take effective measures to improve the current situation of antibiotic abuse and antimicrobial resistance.

Use of Clinical Practice Guideline to Improve Management of Osteoarticular Infections in Children.

Osteoarticular infections (OAIs) in children pose significant risks if incorrectly managed. We introduced a clinical practice guideline (CPG) to decrease use of broad-spectrum and intravenous (IV) antibiotics for OAI treatment. The primary aims of our project were to decrease the percent of patients with empirical broad cephalosporin use to 10% and decrease IV antibiotic therapy on discharge to 20% while increasing narrow-spectrum oral antibiotic use to 80% within 24 months. We used quality improvement methodology to study patients diagnosed with OAIs. Interventions included multidisciplinary workgroup planning, CPG implementation, education, information technology, and stakeholder feedback. Outcome measures were the percentage of patients prescribed empirical broad-spectrum cephalosporins, percent discharged on IV antibiotics, and percent discharged on narrow-spectrum oral antibiotics. Process measures included percent of patients hospitalized on medicine service and infectious diseases consultation. Balancing measures included rates of adverse drug reactions, disease complications, length of stay, and readmission within 90 days. The impact of the interventions was assessed with run and control charts. A total of 330 patients were included over 96 months. The percentage of patients with empirical broad cephalosporin coverage decreased from 47% to 10%, percent discharged on IV antibiotics decreased from 75% to 11%, and percent discharged on narrow-spectrum oral antibiotics increased from 24% to 84%. Adverse drug reactions decreased from 31% to 10%. Rates of complications, readmissions, and length of stay were unchanged. Through development and implementation of a CPG for OAI management, we demonstrated decreased use of empirical broad-spectrum antibiotics and improved definitive antibiotic management.

Risk Factors and outcomes associated with inappropriate empiric broad-spectrum antibiotic use in hospitalized patients with community-acquired pneumonia

Background: Inappropriate broad-spectrum antibiotic use targeting methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa can result in increased adverse events, antibiotic resistance, and Clostridioides difficile infection. In 2019, revised ATS/IDSA community-acquired pneumonia (CAP) guidelines removed healthcare-associated pneumonia (HCAP) as a clinical entity and modified patient factors warranting empiric broad-spectrum antibiotic (BSA) use. As a result, most patients hospitalized with CAP should receive empiric antibiotics targeting standard CAP pathogens. Based on revised guidelines, we evaluated predictors and outcomes associated with inappropriate BSA use among hospitalized patients with CAP. Methods: Between November 2019 and July 2022, trained abstractors collected data on non-ICU adult medical patients admitted with CAP at 67 Michigan hospitals who received either an inappropriate empiric BSA on hospital day 1 or 2 or a standard CAP regimen. Inappropriate empiric BSA use was defined as use of an anti-MRSA or anti-pseudomonal antibiotic in a patient eligible for standard CAP coverage per IDSA guidelines. Patients with immune compromise, moderate or severe chronic obstructive pulmonary disease (COPD), pulmonary complication, or guideline-concordant treatment with BSA were excluded. Data collected included comorbidities, antibiotic use and hospitalizations in the preceding 90 days, cultures in the preceding year, signs or symptoms of pneumonia, hospital characteristics, and 30-day postdischarge patient outcomes. Data were collected through chart review and patient phone calls. Predictors of inappropriate empiric BSA were evaluated using logistic general estimating equation (GEE) models, accounting for hospital-level clustering. We assessed the effect of inappropriate empiric BSA (vs standard CAP therapy) on 30-day patient outcomes using logistic GEE models controlling for predictors associated with the outcome and probability of treatment. Results: Of 8,286 included patients with CAP, 2,215 (26.7%) were empirically treated with inappropriate BSA. The median BSA treatment was 3 days (IQR, 2.5). After adjustments, factors associated with inappropriate empiric BSA treatment included hospitalization or treatment with high-risk antibiotics in preceding 90 days, transfer from a postacute care facility, hemodialysis, support with ≥3 L supplemental oxygen, severe sepsis, leukocytosis, and higher pneumonia severity index (Fig. 1). After adjustments, patients with inappropriate empiric BSA treatment had higher readmissions 30 days after discharge, more transfers to the intensive care unit, more antibiotic-associated adverse events, and longer hospitalizations (Fig. 2). Conclusions: Patients hospitalized with CAP often received inappropriate BSA as empiric coverage, and this inappropriate antibiotic selection was associated with worse patient outcomes. To improve patient outcomes, stewardship efforts should focus on reducing inappropriate BSA use in patients hospitalized for CAP with historic HCAP risk factors or severe CAP without other guideline-directed indications for BSA.Financial support. H.M.S. initiative is underwritten by Blue Cross and Blue Shield of Michigan.Disclosures: None

Quad Fever after Acute Traumatic Spinal Cord Injury

Quad fever is a rare and sometimes fatal condition characterised by sustained high temperatures of 40.8° C (105.4° F) and above, in spinal cord injury patients. Patients are often unresponsive to routine antipyretics and diagnosis is usually one of exclusion after other causes of fever are ruled out. This condition is understood to be secondary to autonomic dysfunction leading to thermoregulatory impairment. In the present case report, a 53-year-old male patient developed a fever of 104°F two days after a traumatic spinal cord injury involving C6-C7 segments. The fever did not respond to paracetamol, empirical broad-spectrum antibiotics or thromboprophylaxis. After ruling out both infectious and non infectious causes of fever, the hyperthermia was attributed to quad fever, a type of neurogenic fever. The patient continued to have non relapsing high fever and died five days after presentation. The case highlights the need to be aware of this differential in cases of high fever following traumatic spinal cord injury, in order to better prognosticate and also avoid unnecessary antimicrobial usage.

Survival rate of odontogenic descending necrotizing mediastinitis. Our experience in last 5 years.

Descending necrotising mediastinitis is one of the most lethal and least frequent forms of mediastinitis. It is a life-threatening infection most frequently originating from an oropharyngeal or odontogenic infection. A retrospective study of 6 patients diagnosed and treated for descending necrotising mediastinitis between 2015 and 2020 is reported. All patients were male, mean age of 34.83 years; 66% were smokers. 83% had an orocervical infection and 34% had initial mediastinal spread. All patients were treated initially with empirical broad-spectrum antibiotics and surgical drainage, with subsequent admission to the Intensive Care Unit; only one of them required tracheostomy. The mean hospital stay was 27.37 days. After a mean follow-up of 6 months, 100% of the cases had a complete recovery. Early diagnosis and surgical treatment combined with improved life-support treatment in intensive care units and broad-spectrum antibiotic therapy leads to a decrease in associated mortality.

Fear of Missing Organisms (FOMO): the discordance among broad-spectrum empiric antibiotic therapy, microbiologic results, and definitive antibiotic therapy for diabetic foot infections and lower extremity osteomyelitis.

Empiric broad-spectrum antibiotic therapy is commonly prescribed for patients hospitalized with diabetic foot infections (DFI) and lower extremity osteomyelitis (OM). The primary objective was to evaluate the concordance between empiric antibiotic therapy, microbiologic results, and definitive antibiotic therapy with a focus on methicillin-resistant Staphylococcus aureus (MRSA) and resistant gram-negative organisms. The secondary objective was to evaluate the negative predictive values (NPV) of select risk factors for MRSA and resistant gram-negative organisms for microbiologic results with these organisms. Retrospective cohort study. Safety-net health system in Ohio. Adults hospitalized and receiving antibiotic therapy for DFI or lower extremity OM in 2021. For 259 unique patients, empiric therapies with activity against MRSA and resistant gram-negative organisms were administered to 224 (86.5%) and 217 (83.8%) patients, respectively. Definitive therapies with activity against MRSA and resistant gram-negative organisms were administered to 91 (35%) and 74 (28.6%) patients, respectively. Of 234 patients with microbiologic testing, 29 (12.4%) had positive cultures with MRSA and 41 (17.5%) with resistant gram-negative organisms. The NPVs of risk factors for MRSA and resistant gram-negative organisms for the absence of these organisms in culture were 91% and 85%, respectively. For patients hospitalized with DFI and lower extremity OM, our data suggest opportunities for substantial reductions in empiric therapies with activity against MRSA and resistant gram-negative organisms. The absence of risk factors for these organisms was reasonably good at predicting negative cultures with these organisms.

Are There Any Changes in the Causative Microorganisms Isolated in the Last Years from Hip and Knee Periprosthetic Joint Infections? Antimicrobial Susceptibility Test Results Analysis.

PJIs following total hip and knee arthroplasty represent severe complications with broad implications, and with significant disability, morbidity, and mortality. To be able to provide correct and effective management of these cases, an accurate diagnosis is needed. Classically, acute PJIs are characterized by a preponderance of virulent microorganisms, and chronic PJIs are characterized by a preponderance of less-virulent pathogens like coagulase-negative staphylococci or Cutibacterium species. This paper aims to analyze if there are any changes in the causative microorganisms isolated in the last years, as well as to provide a subanalysis of the types of PJIs. In this single-center study, we prospectively included all retrospectively consecutive collected data from patients aged over 18 years that were hospitalized from 2016 through 2022, and patients that underwent a joint arthroplasty revision surgery. A standardized diagnostic protocol was used in all cases, and the 2021 EBJIS definition criteria for PJIs was used. 114 patients were included in our analysis; of them, 67 were diagnosed with PJIs, 12 were acute/acute hematogenous, and 55 were chronic PJIs. 49 strains of gram-positive aerobic or microaerophilic cocci and 35 gram-negative aerobic bacilli were isolated. Overall, Staphylococcus aureus was the most common isolated pathogen, followed by coagulase-negative staphylococci (CoNS). All cases of acute/acute hematogenous PJIs were caused by gram-positive aerobic or microaerophilic cocci pathogens. Both Staphylococcus epidermidis and methicillin-resistant S. aureus were involved in 91.66% of the acute/acute hematogenous PJIs cases. 21.8% of the chronic PJIs cases were caused by pathogens belonging to the Enterobacterales group of bacteria, followed by the gram-negative nonfermenting bacilli group of bacteria, which were involved in 18.4% of the cases. 12 chronic cases were polymicrobial. Based on our findings, empiric broad-spectrum antibiotic therapy in acute PJIs could be focused on the bacteria belonging to the gram-positive aerobic or microaerophilic cocci, but the results should be analyzed carefully, and the local resistance of the pathogens should be taken into consideration.

Necrotizing Fasciitis due to Streptococcus constellatus in a Patient with Uncontrolled Diabetes and Bilateral Diabetic Foot Ulceration

Introduction. Streptococcus constellatus is commensal flora of the oropharyngeal, gastrointestinal, and genitourinary tracts with a proclivity for abscess formation. Bacteremia due to S constellatus is rare; however, rising incidences have been reported, particularly in patients with diabetes. Prompt surgical debridement and antibiotic therapy with a cephalosporin are the mainstays of treatment. Case Report. The case presented here involves a patient with poorly controlled diabetes who had necrotizing soft tissue infection secondary to S constellatus. The infection originated from bilateral diabetic foot ulcerations that led to bacteremia and sepsis. Conclusion. Immediate source control with wide and aggressive surgical debridement, initial empiric broad-spectrum antibiotic therapy followed by tailored treatment based on deep operative cultures, and staged closure led to effective limb-salvage and life-sparing intervention for this patient.

Patterns of Antibiotic Use in The One Hour Bundle Treatment of Sepsis

Introduction: Sepsis and septic shock are major health problems, affecting millions of people worldwide and a leading cause of death. Administration of broad-spectrum empiric antibiotics as a one hour sepsis bundle treatment is associated with antimicrobial resistance which has various adverse effects and reduces the quality of health services. The aim of this research was to determine the pattern of empiric antibiotic use in the management of one hour bundle of sepsis at Haji Adam Malik General Hospital Medan. Method: This study used a descriptive method from November 2022 to December 2022 in the Emergency Room (ER), Medical Inpatient Room, Surgical Inpatient Room, and Adult Intensive Care Unit (ICU) of Haji Adam Malik General Hospital Medan. This study used a consecutive sampling technique to recruit 42 sepsis patients who were given a one hour bundle of sepsis according to the inclusion and exclusion criteria. This descriptive analysis was used to determine the characteristics of the sample, namely age, sex, culture results, and antibiotic sensitivity test results. Results: The most common use of antibiotics in the one hour bundle sepsis strategy was ceftriaxone 1 gram in 20 patients (47.6%), Ampicillin-Sulbactam 1.5 grams in 10 patients (23.8%), Levofloxacin 750 mg in 6 patients (14.3%), Meropenem 1 gram in 4 patients (9.5%), and Ciprofloxacin 200 mg in 2 patients (4.8%). Conclusion: Antibiotic administration time is less than 1 hour in the one hour bundle strategy carried out in the ER. Most of the antibiotics given are in accordance with the antibiotic sensitivity test results, but there are still some patients who still experience resistance to the antibiotics.given so it is important to always or immediately carry out culture and sensitivity tests on patients so that the antibiotics given can be more optimal

900: A REPORT OF DISSEMINATED HISTOPLASMOSIS IN AN IMMUNOCOMPROMISED PATIENT FOLLOWING COVID-19 INFECTION

Introduction: Histoplasmosis results from spore inhalation of Histoplasma capsulatum, an endemic fungus in the soil of the Ohio and Mississippi River Valleys of the United States. While the majority of infections with H. capsulatum are asymptomatic and self-limited, immunosuppressed patients may develop severe, disseminated disease. Few reports have described disseminated histoplasmosis following SARS-CoV-2 (COVID-19) infection such as described in this case. Description: A 69-year-old female was evaluated for shortness of breath. Her medical history was significant for rheumatoid arthritis on methotrexate and recent COVID-19 infection treated with dexamethasone. Initial CT-angiography of the chest showed patchy bilateral ground glass opacities. She had leukopenia with white blood cell count of 1.3 K/uL and elevated procalcitonin of 5.88 ng/mL. Broad spectrum empiric antibiotics were initiated. On day 6, the patient decompensated and required ICU transfer. Urine histoplasma antigen, M and H precipitin bands, and serum galactomannan antigen returned positive. Amphotericin B was initiated. The patient underwent bronchoscopy with bronchoalveolar lavage showing atypical reactive macrophages with rare intracellular organisms suspicious for fungi. Repeat CT of the chest, abdomen, and pelvis showed extensive bilateral ground glass opacities, bilateral pulmonary calcifications consistent with granulomas, and calcifications in the spleen and liver. On hospital day 10, the patient required intubation due to hypoxemic respiratory failure. Despite appropriate antifungal therapy, she had worsening encephalopathy, leukocytosis, erythema nodosum, and renal failure. She passed away on day 19. Discussion: This case highlights the development of disseminated histoplasmosis in an immunocompromised adult following COVID-19 infection. It was not until treatment with high dose glucocorticoids that the patient developed disseminated disease and declined. It is important to be aware of the impact that the COVID-19 pandemic has on the emergence of infectious disease and the role its treatment plays in immune suppression. Disseminated histoplasmosis is a consideration for immunocompromised patients in high risk, H. capsulatum endemic areas who are being treated for COVID-19 with high doses of steroids for prolonged periods.

1161: CANNABIS INTOXICATION: A RARE CAUSE OF LACTIC ACIDOSIS

Introduction: Lactic acidosis is common in critically ill patients and has a variety of etiologies. While sepsis, hemorrhage, and shock are the most common causes of lactic acidosis, a subset of patients have no obvious cause. Drug and medication toxicity remains a rare cause of lactic acidosis that providers often fail to recognize. Here, we present a rare case of lactic acidosis due to acute marijuana intoxication. Description: A 26-year-old male with no prior history of marijuana use was brought into the emergency department with complaints of shortness of breath and palpitations after ingesting ice cream containing cannabis. Per EMS, the patient was found screaming for help due to his symptoms but evidently with altered mentation. On arrival, the patient was febrile to 101.9 F with a heart rate of 156 bpm; he was normotensive and saturating well on room air with a normal respiratory rate. Laboratory studies were significant for an elevated lactate level of 4, a white blood cell count of 11, and a urine drug screen positive for THC. The patient was given empiric broad-spectrum antibiotics, 2 liters of lactated ringer’s, and IV naloxone with no improvement in mental status. Studies and physical examination did not reveal any source of infection. After careful monitoring, the patient’s mental status recovered and lactic acid cleared with supportive measures. The patient was later discharged safely home with appropriate follow-up. Discussion: Poisoning is one of the leading causes of injury-related casualties in the United States, and lactic acidosis is a widely used predictor to stratify patients who are at increased risk for mortality. Elevated lactate levels result from an imbalance between lactate metabolism and production. Synthetic cannabinoids have been established as rare causes of lactic acidosis. Chronic marijuana use has been associated with lactic acidosis by way of thiamine deficiency and gastrointestinal beriberi corrected promptly with vitamin administration. There are no reported cases linking acute marijuana use and lactic acidosis development in the absence of infection, hemodynamic compromise, or seizures. It is important to keep drug ingestion and intoxication in mind as important causes of lactic acidosis in the absence of other apparent etiologies.